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Impact of measles resurgence to the Region In 2011 an eightfold increase over the previous annual average of 156 cases between 2003 and 2010. Most common genotypes identified were D4 and B3 174 measles virus importations were detected in the Region in 2011

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The role of the laboratory in a context of low incidence  Pregnant women  Post-vaccine  False positives or cross-reaction  False negatives: is it a problem in this stage of elimination? –These cases should be investigated on a case- by-case basis taking the epidemiological information into account –A second blood sample –Additional tests may be required

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Efforts maintaining the elimination of endemic disease is more expensive than eliminating the disease Health care-associated measles outbreak in the United States after an importation: challenges and economic impact An infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care-associated measles outbreak involving 14 cases in 2008. The 2 hospitals spent US$799,136 responding to and containing 7 cases in these facilities. community partners. J Infect Dis. 2011 Jun 1;203(11):1517-25. J Infect Dis. The Cost of Containing One Case of Measles: The Economic Impact on the Public Health Infrastructure—Iowa, 2004 The containment costs of 1 measles case in this outbreak were high. The costs to the Iowa public health infrastructure of preventing the spread of disease from these cases were $140 000. Pediatrics 2005;116:1--4.

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Containment costs for a measles outbreak in Indiana, USA - 2005 Costs itemUnitary cost (USD) Cost per patient4,932 Wages and salaries108,592 Overhead30,431 MMR vaccine and immune globulin 21,692 Mileage1,610 Other5,360 TOTAL167,685 Source : Parker A, Staggs W, Dayan G et all. Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States. The New England Journal of Medicine, Vol 355, No 5, August 3, 2006 Total number of cases was 34; the majority was among 5-19 years old and 32 lacked evidence of measles vaccination.

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Estimated costs of containing measles outbreaks in selected LAC countries Studies suggests that economic analyses may need to go beyond the costs of individual illness to account for the costs of protecting society, particularly when countries are close to elimination. Country# of cases Scope of outbreak control activities Cost (USD)* Chile (2009)1Limited to 1 municipality12,400 Peru (2009)1 1 municipality in Peru and 1 in Ecuador 20,300 Ecuador (2011-2012) 266Nationwide 8.5 million *Estimated costs include outbreak investigation, follow-up of contacts and vaccination activities Source: Country reports to FCH/IM

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Characterization of the affected population Other factors Over crowded inpatient wards High risk groups: unvaccinated persons (religious groups or other groups that reject vaccination) or in specific geographic areas, such as in indigenous communities, in large cities (especially on the peripheries), and in rural and border areas with limited access to health care.

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Laboratory analysis of measles / rubella in serum samples of the dengue IgM-negative cases with presence of fever and rash in three stages during the outbreak: 1. Analysis before the detection of the first measles case to see previous circulation of measles virus 2. Analysis during the outbreak in provinces, which have not reported confirmed cases; 3. In order to provide evidence of not having measles virus circulation, collected specimens should be collected also within the last three months after detection of the last case. Outbreak response: dengue analysis

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Fuente: Base de Datos Guayas :MESSS-ISIS Challenges  Communications between epidemiology and laboratory teams - the regular meeting of the EPI teams, surveillance and laboratory is recommended to conduct the analysis of the cases, especially the last cases reported  Private sector participation – involvement of the private clinics and the laboratories in detecting and notifying the suspected and confirmed cases

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Maintain the achieved results: Development of plans with partners and Multi-annual plan for the Expanded Program on Immunization 2011–2015 Strategies implementation Phase 1: Maintain and strengthen the achievements of AISE with short-term activities such as the introduction of new vaccines, increased immunization coverage and strengthening epidemiological surveillance Phase 2: Focuses on improving and sustaining the performance of routine immunization program

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Maintain high-quality, elimination-standard surveillance, including full compliance with indicators, and ensure timely and effective outbreak response measures to any wild virus importation  Implement external rapid assessments of measles, rubella, and CRS surveillance systems to increase robustness and quality of case detection and reporting and strengthen registries of congenital anomalies;  Conduct active case searches and review the sensitivity of surveillance systems in epidemiologically silent areas;  Involve the private sector in disease surveillance with a special focus on inclusion of private laboratories in the Regional Measles and Rubella Laboratory Network;  Enhance collaboration between epidemiological and laboratory teams to improve measles and rubella surveillance and the final classification of suspected cases;  Improve molecular genotyping of the confirmed cases throughout outbreaks

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Maintain high population immunization coverage against measles and rubella (>95%)  Implement rapid coverage monitoring to identify populations susceptible to measles and rubella, focusing particularly on localities of high-risk populations: live in high-traffic border areas, live in densely populated areas such as urban fringe settlements, live in areas with low vaccination coverage or high vaccination dropout rates, live in areas not reporting suspected cases (epidemiologically silent), live in areas of high population density that also receive a large influx of tourists and other visitors, especially workers related to the tourism industry (such as those related to airports, seaports, hotels and hospitality sector, tour guides) as well as those in low density or isolated areas (ecotourism destinations), are geographically, culturally, or socioeconomically difficult to reach, and are engaged in commerce/trade (such as through fairs, markets) or live in highly industrialized areas;  Implement high-quality follow-up vaccination campaigns.

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–Plan of Action to maintain the Regional elimination of endemic measles and rubella was approved in the 28 th Pan American Sanitary Conference How to maintain the regional measles/rubella elimination?

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Improved access to IM service delivery Integrating immunization services with other health services Organizing the network of service providers Improving access to immunization services Organizing Immunization service delivery Identify the best ways to increase uptake and the vaccination coverage

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Regional Documentation and Verification Process Status: Regional report with the plan of action was presented to the Governing Bodies of the Pan American Health Organization on progress made in the implementation of Resolution CSP27.R2 18 th of September 2012 Conclusion: After careful analysis of the reports submitted by the National Commissions and Subregional Commission: –It appears that the interruption of endemic measles and rubella virus transmission has been achieved –The Region of the Americas continues to be exposed to high risk of virus importations -the countries have reported weaknesses and failures in their national surveillance systems and routine immunization programs, which make them particularly vulnerable to the risk of reintroduction of viruses that can cause outbreaks.

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Reported MMR1 and MMR2 coverage Latin America, US and Canada, 2011 * Haiti coverage for MR vaccine in children<1 year of age Source: Country reports through the PAHO-WHO/UNICEF Joint Reporting Form (JRF), 2012 95%

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Background of the Ecuadorian measles outbreak In EW 24, 2011, the surveillance system caught in the parish Latacunga Canton Latacunga, Cotopaxi province, a suspected case of 2-year-old, who was later confirmed with genotype D4. No source of infection identified. In EW 28-29 two cases from the parish Atahualpa, Canton Ambato, Tungurahua province were identified (11 months and 2 years old), confirmed with genotype B3. No source of infection identified 327 confirmed measles cases (263 in 2011 and 69 in 2012) have been reported (EW28/2011 to EW37/2012) In EW 24, 2011, the surveillance system caught in the parish Latacunga Canton Latacunga, Cotopaxi province, a suspected case of 2-year-old, who was later confirmed with genotype D4. No source of infection identified. In EW 28-29 two cases from the parish Atahualpa, Canton Ambato, Tungurahua province were identified (11 months and 2 years old), confirmed with genotype B3. No source of infection identified 327 confirmed measles cases (263 in 2011 and 69 in 2012) have been reported (EW28/2011 to EW37/2012)

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Haiti: Sustainability The intensification activities are planned in a way that build upon what already exists and with the aim of leaving a routine vaccination program strengthened: Political commitment: Visibility of the routine program, and the coordination between national and international partners Micro-planning: Staff trained in micro-planning, planning tools, areas of responsibility, well-defined target population, maps available Training: pool of trained people, training of trainers, training materials.

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Maintain the role of the laboratory in a context of low incidence Occurrence of sporadic positive IgM: False positive or true positive? The correct classification of the case depends on the review of laboratory results and clinical and epidemiological data (last vaccination, contact with international visitors, travel history within 21 or 23 days of rash onset). Probability of false negative IgM results: First blood sample collected <= 3 days of rash onset Strongly suspected measles or rubella: recent travel, exposure and vaccination history. Additional tests may be required: Viral detection (RT-PCR) or viral isolation Second blood sample (IgM, IgG) Avidity Test Differential Diagnosis: (dengue, Parvo B19, HHV-6,...)